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Recognizing Imminent Death. Barb Supanich,RSM,MD Medical Director, Palliative Medicine June 26,2007. Goals. To increase your knowledge and skills in identifying common symptoms of imminent death. To increase your knowledge regarding treatment of common imminent death symptoms.

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Recognizing imminent death

Recognizing Imminent Death

Barb Supanich,RSM,MD

Medical Director, Palliative Medicine

June 26,2007


Goals
Goals

  • To increase your knowledge and skills in identifying common symptoms of imminent death.

  • To increase your knowledge regarding treatment of common imminent death symptoms.

  • Learn and use the PPS.


Objectives
Objectives

  • Understand the three stages of the syndrome of imminent death.

  • Understand EBM treatment approaches utilized in caring for patients who are imminently dying.

  • Improve your ability to integrate the patient’s choices in their EOL care.


Early symptoms
Early Symptoms

  • Clinician Recognition

    • Primarily bed bound

    • Loss of interest/ability to eat or drink

    • Altered mental status

  • Family Issues

    • Confusing language of physician - - “doing poorly” vs. “patient is dying”

    • Addressing patient goals for treatments at the end of life.

    • Basic care issues: hygiene, eating, incontinence


Mid stage of imminent death
Mid Stage of Imminent Death

  • Further decline in mental status

    • Less responsive

    • Obtunded

  • Low grade fevers

  • Oral secretions

  • Loss of swallowing reflex

  • “Death rattle”


Late stage of imminent death
Late Stage of Imminent Death

  • Altered respiratory pattern

  • Cool extremities

  • Fever

  • Coma

  • Death

  • Time course through various stages is variable


Pps palliative performance scale
PPS: Palliative Performance Scale

  • 100 to 0% scale

  • 100%: Perfect Health

  • 0%: Death

  • 100-80%: NL activities

  • 60-70%: Reduced activity, self care and eating

  • 50%: Significant disease, markedly ↓ ADL, eating, sleeping more during day.


Palliative performance scale
Palliative Performance Scale

  • 40%: Mainly in bed, ↓ adl’s, less eating, ↓ LOC.

  • 30%-10%: Bedbound, Full care, sleeps most of day, ↓↓ LOC.

  • 0%: Death

  • Guide for docs, nurses and family members.


Treatment of e s symptoms
Treatment of E/S Symptoms

  • Shortness of breath (mild):

    • Roxanol, 5 mg po/sl q 4h, titrate

      • Breakthrough dose: 5 mg q 2h

    • Roxanol 10 mg po/sl q 4h, and titrate

      • Breakthrough dose: 10 mg q 2h

    • For children/frail elderly: Roxanol 2.5 to 5 mg po/sl q 4h

      • Breakthrough dose: 2.5-5 mg q 2h


Treatment of terminal symptoms
Treatment of Terminal Symptoms

  • Severe Dyspnea

    • Morphine sulphate:

      • 10-20 mg SL every 30-60 minutes

      • 2 mg/hr continuous drip

  • Use breakthrough doses of 50% of baseline q 1-2h as needed:

    • Titrate aggressively –

      • 1mg/hr every 30 minutes until relief of sx


Symptom treatment
Symptom Treatment

  • Nausea and Vomiting

  • Antihistamines:

    • Meclizine 25-50 mg po q 6h

    • Benadryl 25-50 mg po q 6h (not elderly)

  • Acetylcholine antagonists

    • Scopolamine transdermal patches 1 q 72h

  • Serotonin antagonists

    • Ondansetron 8 mg IV q 8h


Nausea treatments
Nausea Treatments

  • Prokinetic Agents

    • Metaclopramide 10-20 mg po q 6h

  • Dopamine Antagonists

    • Promethazine 12.5-25 mg po/pr q 4-6h

  • Benzodiazepines

    • Lorazepam 0.5-2.0 mg po/sl q 1h until settled, then q4-6h


Terminal sx treatment
Terminal Sx Treatment

  • Anxiety

    • Lorazepam 0.5-2.0 mg po/sl or IV q 1h until settled, then dose q 4-6h to keep comfortable

    • Diazepam 5-10 mg po/iv q 1h until settled, then dose q 6-8h until comfortable

    • Clonazepam 0.25-2.0 mg po q 12h

  • Personal hygiene

    • Incontinence

    • Pressure sores

    • AVOID hydrogen peroxide, hypochlorites, povidone-iodine


Terminal sx treatment1
Terminal Sx Treatment

  • Delirium

    • If possible treat underlying cause

    • Use anxiolytics or antipsychotics as needed

    • Non-pharmacologic approaches:

      • Re-orient patient

      • Familiar persons

      • Familiar sounds, smells, pictures

      • Use of lavender extract


Terminal sx treatment2
Terminal Sx Treatment

  • Death Rattle

    • Scopolamine patch q 72 h

    • Better positioning, proper mouth care

  • Altered respirations

    • Better positioning

    • Proper mouth care

    • Use of morphine

  • Restlessness

    • Massage, music, soothing talking

    • Use of anxiolytics

    • CARE Channel


Eol care
EOL Care

  • Coolness/mottling

    • Keep patient warm

  • Sleeping

    • Sit with person

    • Pray with person (if desires)

    • When requested, speak quietly and directly

  • Disoriented

    • Clear, truthful communication

    • Reorientation, clear explanations

  • Eating less

    • Offer small amounts of fluid/food

    • Glycerine swabs, ice chips


Terminal restlessness
Terminal Restlessness

  • Severe agitation

    • Not well controlled with usual tx.

  • Treatment options

    • Increase dose of Ativan –2 mg every 6h

    • Consider use of Ativan drip-O.5-1 mg/h

    • Consider use of Midazolam drip 1 mg/h

    • Consider use of Propofol 5-10 mg/hr


Pain management
Pain Management

  • Morphine Drips

    • MS 2 mg/hr

    • Titrate by 1mg/hr every 15-20 minutes until pain is relieved per patient

    • Adjust basal rate by 50% of total boluses in prior 24 hours


Pain management1
Pain Management

  • Morphine SC Infusions

    • SC can tolerate up to 3 cc/hr

    • Use 25 or 27 gauge needle

    • Can use morphine, dilaudid, or fentanyl

    • Morphine IV:SC is 1:1

    • Others, would check with pharmacist


Other eol issues
Other EOL Issues

  • Feeding and Nutrition Issues

    • Cachexia and anorexia at EOL

    • Normal part of dying process

    • NOT starving the patient

    • Give control of nutrition style to patient

    • Help refocus caring needs of family to other areas of concern for the patient


Other eol issues1
Other EOL Issues

  • CPR discussed as a treatment option

    • Discuss beneficial vs. nonbeneficial

    • Known data on CPR for terminal conditions

  • Compassionate Wean Protocol

    • Prepare family and patient

    • Provide appropriate ativan and morphine doses prior to wean

    • Start appropriate drip of morphine

    • Withdraw ventilator, ETT


Summary
Summary

  • Discussed common sx of Imminent Death

  • Discussed treatment of common sx of Imminent Death

  • Learned the PPS

  • Discussed other key sx and their management at the EOL

  • Website: https://hch.palliativecare.webexone.com

  • THANK YOU !


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